Comments on comparing analgesic efficacy of different local blocks after laparoscopic cholecystectomy.

Abstract

In a single-center randomized controlled trial including 60 patients who underwent laparoscopic cholecystectomy, Cho et al. [1] compared the postoperative analgesic efficacy of the modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) and subcostal transversus abdominis plane block (TAPB) and showed no significant difference in postoperative pain scores, cumulative analgesic consumption, patient satisfaction with pain control, or incidence of postoperative nausea and vomiting between two techniques. The authors should be congratulated on their excellent work. However, beyond the limitations described in the discussion section, we had several questions about the design and results of this study and wished to get the authors’ responses. First, as an important component of multimodal analgesic strategy, basic analgesics, such as acetaminophen and ketorolac, were intravenously administered during surgery. However, it was unclear why these drugs were not continuously used after surgery. The current protocols for enhanced recovery after surgery for laparoscopic surgery recommend that administration of basic analgesics should be started before or during an operation and regularly executed after surgery, while opioids should only be reserved for rescue analgesia [2]. Even without local blocks, a well-designed multimodal analgesic strategy can also adequately control postoperative pain, keep the patient comfortable, as well as decrease the opioid dose and adverse effects by the synergistic or additive effects of various types of analgesics in the patients undergoing laparoscopic cholecystectomy [3]. Jung et al. [4] demonstrated that even the addition of the bilateral subcostal and lateral TAPB to a standard multimodal analgesic strategy does not improve analgesic outcomes or quality of recovery following laparoscopic cholecystectomy. Second, to keep the patient comfortable, a numeric rating scale (NRS) score of 3 or less is generally considered as satisfactory postoperative pain control [2]. According to figures 3–6 in the article by Cho et al. [1], we noted that the median NRS score of maximum pain intensity during movement within the first 12 hours postoperatively were 5 or more, with large interquartile ranges. Furthermore, a significant proportion of patients had median NRS scores of 4 or more at rest and during coughing and movement within the first 6 hours postoperatively. These results indicate that most patients experienced moderate